The Centers for Medicare and Medicaid Services (CMS) guidelines for Teaching Physicians, Interns and Residents (2017) are specifically directed to the role of the teaching physician, although they can be applied to teaching nurse practitioners who care for Medicare patients.
The CMS guidelines and NTF criteria for the ratio of preceptor to student are reasonable and explicitly state:
- Identify the preceptor as the primary provider for the patient being seen by students.
- Review all subjective and objective findings, diagnostics, and plans of care.
- The preceptor is expected to validate findings on physical examination, review laboratory tests, and confirm differential diagnoses and management plans with students before the discharge of the patient. A review by the preceptor must be documented in the record, indicating that the preceptor has examined the patient and agrees with the findings and plan as written by the student. It is customary that the preceptor cosign all records for which the student has provided documentation.
As an expert clinical practitioner, the preceptor has mastered a variety of ways of thinking that contribute to the process of clinical reasoning. Teaching the student how to use these ways of thinking helps. The process of teaching clinical reasoning guides the student in learning new ways of thinking in clinical practice. Students should be asked to:
- Reflect and describe the process of identifying a specific diagnosis or differential, select laboratory tests, prescribe medications, or recommend a follow-up schedule
- Use accepted guidelines and standards of care
- Use the latest evidence in development of management plans
- Critically analyze the guideline/standard of care and determine how it should be implemented or adapted to the individual patient scenario
- Reflect on previous patient encounters and compare and contrast components of the assessment
